Published in the March 2010 issue of Today’s Hospitalist
A year ago, Darren Sommer, DO, MPH, received a new directive from his VPMA: Come up with a policy to accept direct admissions. Dr. Sommer, the hospitalist medical director at Southeastern Regional Medical Center in Lumberton, N.C., explained that his group would rather not accept direct admissions because of concerns about patient safety.
“The VPMA understood those concerns,” says Dr. Sommer, “but he explained that we would lose a lot of business from our primary care colleagues “and that if we didn’t offer this service, someone else would. He wanted to come up with a happy medium.”
Dr. Sommer is hardly alone in being asked to find a way to make direct admissions work. Primary care physicians want the convenience of a direct admission for their patients, and hospital administrators are looking to unclog their EDs and boost patient satisfaction scores.
But finding a “happy medium” that balances appropriate care with the needs of outpatient physicians and administrators is not always easy. As a result, some groups have decided to refuse direct admissions, particularly as the number of referring doctors and unfamiliar patients continues to climb.
For groups like Dr. Sommer’s, however, that are becoming more friendly toward direct admissions, that move is possible with innovations in the ED and in hospitalist staffing. Those changes not only make direct admissions possible, but ensure that patients “whether admitted directly to the floor or seen in the ED “are safe.
A new push for formal policies
At Lancaster General Hospital, a 550-bed facility in Lancaster, Pa., hospitalist director O. Scott Lauter, MD, says that the hospitalists have been taking direct admissions from referring doctors “forever.” But within the last six to 12 months, he adds, the group has formalized its direct-admission policy by creating specific criteria.
To be eligible for a direct admission, patients must be in the primary care physician’s office when the doctor calls, their diagnosis must be fairly certain, and they can’t be critically ill or unstable. A good example is a patient with cellulitis who’s failed to respond to outpatient antibiotics and is now being admitted directly to the floor for IV therapy.
“These are patients who need no additional triage,” says Dr. Lauter, so they don’t stand to benefit from the much faster turnaround in lab and test results available only through the ED.
Patients not eligible for a direct admission include those whose diagnosis is uncertain or unstable “they have shortness of breath, chest pain, GI bleeding or weakness, for example ” and patients not in the office who have been in touch with the outpatient physician only by phone.
What can go wrong
While those criteria can screen out many inappropriate direct admissions, they aren’t enough to satisfy some hospitalists who have deep-seated concerns about diagnostic misperceptions “or even misdiagnoses “from referring physicians.
At the 99-bed Auburn Memorial Hospital in Auburn, N.Y., for example, hospitalist director James Leyhane, MD, explains that his group banned direct admissions in 2008 with only some rare exceptions, such as a patient previously admitted for a skin infection that isn’t healing.
Before the ban, Dr. Leyhane explains, some patients admitted directly to the floor with chest pain were found to be having “a full-blown MI and then urgently shipped out for a cath.” Others needed to be transferred from the floor for dialysis, which likewise isn’t available in the hospital.
Then there was this problem that cropped up from some outlying referring groups. “What was supposed to be a medical admission,” Dr. Leyhane says, “turned out to really be a social issue. Then it became our problem.”
Familiar patients vs. unknown
Those concerns are echoed by Kamal S. Ghei, MD, a hospitalist with Saint Francis Memorial Hospital in San Francisco. While more direct admissions would reduce ED congestion, he says, most of the hospitalists in his group are reluctant.
All too often, Dr. Ghei explains, primary care doctors downplay patients’ symptoms to get them into the hospital faster, or patients may simply be sicker than the outpatient physician realizes. Even cellulitis patients directly admitted for IV antibiotics, for example, may have a high lactic acid and need a septic workup or they may be found on ultrasound to have a DVT or abscess.
“If ultrasound or labs had been done in the ED, the surgeon would have been called right away for the abscess rather than the next day,” Dr. Ghei points out. Similarly, a patient found to have a DVT in the ED could start anticoagulation right away, while a high lactic acid would prompt more immediate, aggressive treatment.
On the floor, says Dr. Ghei, hospitalists doing direct admissions end up providing more one-on-one time with those patients as each new test result comes back. “That delays care delivery to that patient and, indirectly, to other patients,” he adds. “Primary care doctors may be trying to save time for the direct admit, but overall, direct admissions can delay total time for all patients.”
That situation is exacerbated, Dr. Ghei says, by the fact that many patients admitted to the Saint Francis hospitalist team are “brand new to us.”
Hospitalists in hospitals with direct-admission policies agree that familiarity “with both referring doctors and patients ” is a key to those policies’ success. At Lancaster General, for instance, Dr. Lauter says that up to 90% of patients called in by referring physicians are directly admitted, not sent first to the ED for tests or triage. However, most referring physicians worked in the same multispecialty group as the hospitalists until July of last year, when the hospitalist group switched to direct hospital employment. That long history makes for a very good relationship that works both ways.
“We’re very familiar with these physicians, and we trust them,” says Dr. Lauter. “Conversely, if we have concerns about a direct admission, we don’t get any pushback. They trust our judgment too.”
Incentivizing direct admissions
Familiarity also helps make direct admissions successful for Midwest Hospital Specialists, a local hospitalist group based in Kansas City that has 38 hospitalists working in eight hospitals. All the hospitals allow direct admissions, and one even gives hospitalists financial incentives to accept them.
Thomas Frederickson, MD, the hospitalist medical director at Overland Park Regional Medical Center in Overland Park, Kan., says that “a very modest” portion of the group’s incentive package at that hospital is tied to the hospitalists directly admitting at least 50% of patients phoned in by referring doctors or outlying hospitals. “Making the admission process simpler is a huge marketing issue, particularly for rural emergency departments,” he says.
According to Dr. Frederickson, direct admits rarely show up sicker than represented. “My experience,” he explains, “is that primary care physicians are going to be cautious with a diagnosis. It’s very rare that we accept a patient on the floor who really should be in the ICU or the emergency room.”
He also points to the group’s long track record. “We’ve been operating in the Kansas City area for 12 years and are by far the largest and oldest group in the city,” he explains. “We know these folks.”
A one-call process
To help facilitate direct admissions, Dr. Frederickson’s group keeps one hospitalist in each hospital on call.
Once a referring physician or outlying hospital calls a central admit line and gives the patient’s information, an operator patches the call directly through to the on-call hospitalist. While his group does not use dedicated admitters, Dr. Frederickson says the on-call physician charged with taking care of direct admits usually is given a lighter rounding load.
At Lancaster General, Dr. Lauter’s group does use an admitting and consulting team. Every day, one of those physicians is designated “first call” and handles calls from the direct-admission pager.
Every month, Dr. Lauter says, he e-mails referring physicians a schedule of “first call” doctors, along with those physicians’ pager numbers. “It’s a one phone-call process,” he says. “We’ve had a lot of positive feedback.”
At Southeast Regional, Dr. Sommer’s group has made the one-call process even simpler. When the group decided to implement direct admissions, one of the first steps it took was to throw out its pagers and buy BlackBerrys.
His group also relies on separate admitters, one of whom carries the direct-admission BlackBerry. Referring physicians who want a direct admission just have to keep that one number available.
“That’s been a huge plus,” says Dr. Sommer. “The primary care physician doesn’t have to call our office or sit on hold with the emergency department.”
Building in a safety net
But direct admissions must fall within certain parameters, Dr. Sommer explains: Patients have to be stable without any critical findings, and they won’t be accepted after 4 p.m., when admissions begin to spike.
The hospitalists in Dr. Sommer’s group also suggested an innovation to ensure that admitting hospitalists have a safety net if patients are sicker than expected. Their proposal, which was implemented, was to set up a direct admission area within the emergency department.
Patients phoned in are flagged as a direct admit in the ED. Once patients check in and have vitals taken, they see the admitting hospitalist in that designated area.
Patients found to have a hemoglobin of 4 on the CBC, says Dr. Sommer, can be immediately transitioned to an emergency physician. While direct admits can’t walk from the parking lot to a floor bed, he says, they spend between a half hour and an hour in the ED’s direct admission area, not three to four hours in the ED queue.
“That lets the community doctor and the patient bypass the majority of an ED visit,” Dr. Sommer notes. “But it also ensures that the direct admission is appropriate, and that’s been our happy medium.” While Dr. Sommer says the innovations have helped, the key ingredients behind the new policy’s success are hospitalist buy-in and effort.
“If the hospitalists didn’t answer the phone, work with the community physicians and support the service,” he says, “it wouldn’t succeed.”
Even hospitalist groups that shy away from direct admissions are working with their EDs to fast track stable admissions.
At Auburn Memorial, Dr. Leyhane says, hospitalists will OK rapid triage for one or two admissions a month, having patients stop in the ED for labs and tests, with hospitalists seeing them there.
“The ED doc doesn’t even get involved,” says Dr. Leyhane. “That’s something we can do because we’re a smaller hospital.”
Phyllis Maguire is Executive Editor of Today’s Hospitalist.
Direct pediatric admissions in academic vs. community hospitals
TWO YEARS AGO, Monroe Carell Jr. Children’s Hospital in Nashville moved to significantly reduce the number of urgent, same-day direct admissions to the hospitalist group. Paul Hain, MD, associate chief of staff, says the policy wasn’t a reaction to any bad outcome, but a recognition that children “unlike adults “can deteriorate very quickly from respiratory compromise.
However, the academic children’s center has implemented many innovations that fast-track admissions for patients phoned in by pediatricians. All admission calls go to one access center, where operators enter the patient’s clinical information in the hospital’s sophisticated electronic medical record. The EMR system creates a form that Dr. Hain says is “tagged to the ED white board on that child’s record.”
When the child registers in the ED, emergency physicians have an electronic flag directing them to that form. “They know exactly what the referring physician thought was happening,” notes Dr. Hain.
Jack Percelay, MD, a pediatric hospitalist at Saint Barnabas Medical Center in Livingston, N.J., says he understands why academic children’s hospitals might adopt a blanket no-direct-admission policy. But in the community hospitals where he’s worked, pediatric hospitalists can take a more flexible approach.
For one, he says, many community hospitals don’t have a separate pediatric ED. A pediatric hospitalist seeing the patient in the ED or even on the floor might deliver more efficient care than an adult ED doctor performing an initial evaluation.
Familiarity with the referring physician is always a factor, as is the patient’s (reported) condition and “how busy it is on the floor,” Dr. Percelay points out. When he’s called by a referring physician and the patient sounds like “a 50- 50 candidate for direct admission vs. one through the ER,” he’ll try to meet the patient and family in the ED registration area to decide if the child can head directly to the floor.
“Even if the family needs to go to the ER for initial measures,” Dr. Percelay says, “the patient and family are going to get a little bit of VIP treatment.”
The lower volumes and flexibility in community hospitals make such “valet service” possible, he points out. But floor nurses in community hospitals tend to not like direct admissions.
“A direct admission can disrupt their work flow,” says Dr. Percelay. He will talk with floor nurses about his “and their “comfort level with a particular direct admission, then decide whether to see the patient in the registration area or waiting room first.
Advocating with nurses for a direct admission is more successful now, Dr. Percelay admits, “that I have some gray hair.” For junior physicians pushing for direct admissions in community hospitals, he recommends giving in to floor nursing in the absence of a clear policy.
For physicians who want to press the point, Dr. Percelay has this advice: “Go up your own chain of command,” he says, “not theirs.”